Complete Shoulder and Hip Blueprint

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Over the course of this chapter, we have attempted to present a focused approach to the evaluation of the athlete's shoulder that begins with an understanding of the patient's chief complaint and, based on this, immediately forms a differential diagnosis. The accuracy of this differential is enhanced by asking the right questions in the history such as onset, character, duration, clinical course, degree of disability, and response to clinical intervention. This differential-directed approach then guides the remainder of the encounter.

The physical examination of the overhead and throwing athlete remains an even more challenging art. However, with knowledge of various tests and techniques, the examiner can often narrow its focus. The examination should be organized and comprehensive, but with expectations for findings directed by the differential ("going for the money"). Finally, when possible, and especially when pain is a chief complaint, we are liberal in our use of local anesthetic to temporarily and completely relieve the patient's chief complaint as an aid to narrowing the diagnosis.

The advantage of the differential-directed approach is that it establishes a suspected diagnosis at the beginning of the encounter and guides the examiner as to what to look for during the examination. When one elicits expected positive findings, one's suspicions of the diagnosis are strengthened. However, even when the examiner is surprised by unexpected findings, it will redirect him or her toward another diagnosis that is also in the differential.

Formulating a differential at the beginning of the encounter, however, does have its risks. One must be careful not to be convinced too quickly, as overconfidence will lead to a biased interpretation of the physical examination findings and can result in a misdiagnosis. In addition, the quality of the differential and the skill of validating it depend largely on the examiner's knowledge of shoulder pathology and the various forms in which it presents. We have attempted to describe the process of this focused approach and hope that by formulating a short list of diagnoses early in the encounter, the examiner will be more directed, efficient, and accurate in the approach to the athlete's shoulder.

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